Outcome of in vitro fertilization in women 45 years and older who use autologous oocytes

Pregnancy by Oocyte Donation: Reviewing Fetal-Maternal Risks and Complications

Oocyte donation (OD) has greatly improved over the last three decades, becoming a preferred practice of assisted reproductive technology (ART) for infertile women wishing for motherhood. Through OD, indeed, it has become possible to overcome the physiological limitation due to the ovarian reserve (OR) exhaustion as well as the poor gamete reliability which parallels the increasing age of women. However, despite the great scientific contribution related to the success of OD in the field of infertility, this practice seems to be associated with a higher rate of major risky events during pregnancy as recurrent miscarriage, infections and placental diseases including gestational hypertension, pre-eclampsia and post-partum hemorrhage, as well as several maternal-fetal complications due to gametes manipulation and immune system interaction. Here, we will revisit this questioned topic since a number of studies in the medical literature focus on the successful aspects of the OD procedure in terms of pregnancy rate without, however, neglecting the risks and complications potentially linked to external manipulation or heterologous implantation.

Unveiling uterine aging: Much more to learn

Uterine aging is an important factor that impacts fertility, reproductive health, and uterus-related diseases; however, it remains poorly explored. Functionally, these disturbances have been associated with an abnormal hormonal response in the endometrium and decreased endometrial receptivity. Based on emerging evidence, these alterations are mediated via the senescence of endometrial stem cells and impaired decidualization of endometrial stromal cells. Multiple molecular activities may participate in uterine aging, including oxidative stress, inflammation, fibrosis, DNA damage response, and cellular senescence. Over the past decade, several protective strategies targeting these biological processes have afforded promising results, including stem cell therapy, anti-aging drugs, and herbal medicines. However, the currently available evidence is fragmented and scattered. Here, we summarize the most recent findings regarding uterine aging, including functional and structural alterations and potential cellular and molecular mechanisms, and discuss potential protective interventions against uterine aging. Thereby, we hope to provide a comprehensive understanding of the pathophysiological processes and underlying mechanisms associated with uterine aging, as well as improve fecundity and reproductive outcomes in females of advanced reproductive age.

Rare live birth to a 48-year-old woman after embryo transfer with autologous oocyte: A case report

OBJECTIVE

Advanced maternal age and decreased ovarian reserve have been challenges for assisted reproductive technology (ART). Few cases, using autologous oocytes more than 46-years-old, have previously been reported. We seek to show how the age at which autologous oocytes may successfully be employed may be increasing.

CASE REPORT

We report a 47-year-old woman with an anti-Müllerian hormone (AMH) level of 0.24 ng/mL, conceived through in vitro fertilization (IVF) using autologous oocytes. Patient was given an antagonist protocol for ovarian stimulation and one frozen-thawed embryo was transferred. The patient became pregnant. The course of her pregnancy was uneventful and she gave birth to a 3330 gm male baby by cesarean section.

CONCLUSION

Technological advances permit women, who previously would have been considered too old to employ an autologous oocyte, to have a successful pregnancy with a live birth.

Occupational Factors Affecting Women Workers’ Sexual and Reproductive Health Outcomes in Oil, Gas, and Mining Industry: A Scoping Review

Objectives: Globally, female workers workforce in Oil, Gas, and Mining (OGM) industry have increased significantly. The complexities of the OGM operations and the extensive exposure to workplace hazards potentially affect the health status of workers, including sexual and reproductive health (SRH) outcomes of female workers. Yet, the current state of knowledge on SRH issues in OGM contexts seems to be limited and fragmented. This scoping review aims to identify the occupational factors that influence women’s SRH outcomes in OGM industry.

Methods: This scoping review followed the Joanna Briggs Institute’s guidelines (PRISMA) and was conducted in five databases, including the citation chaining via Google Scholar and manual search through relevant organisations and Government websites. Sixteen articles met the inclusion criteria and were analysed.

Results: Despite the scarcity of evidence, chemical and physical are found to be the predominant factors greatly influencing women workers’ SRH outcomes in OGM. Most studies showed menstrual and cycle disorders, and risky pregnancy as key SRH issues. However, menstruation disorder was considerably linked with psychological and organisational factors.

Conclusion: This review suggests further empirical research on the relationship between OGM occupational hazards and women workers’ SRH. This will contribute to improvements in workplace safety legislations, measures, policies, and management systems taking into account women’s needs.

Maternal and perinatal complications according to maternal age: a systematic review and meta-analysis

OBJECTIVE

To evaluate the risk levels for maternal and perinatal complications at >=40, >=45, >50 years old compared to younger controls METHODS: Electronic databases were searched from their inception until March 2021. We included studies reporting pregnancy outcome in pregnant women 40, 45 and 50 years or older compared with controls at the time of delivery. Case reports, and case series were excluded. The primary outcome was the incidence of stillbirth. Meta-analysis was performed using the random effects model of DerSimonian and Laird, to produce summary treatment effects in terms of either a relative risk (RR) with 95% confidence interval (CI). Heterogeneity was measured using I-squared (Higgins I² ). Subgroup analyses in women older than 45 years and in those older than 50 years were performed.

RESULTS

27 studies, including 31,090,631, were included in the meta-analysis. The overall quality of the included studies was moderate to high. The vast majority of the included studies were retrospective cohort studies (21/27), four were population-based studies, and two were cross sectional studies. Women ≥ 40 years had significantly higher risk of stillbirth (RR 2.16, 95% CI 1.86 to 2.51), perinatal mortality, IUGR, neonatal death, admission to NICU, preeclampsia, preterm delivery, cesarean delivery, and maternal mortality compared to <40 yo women (RR 3.18, 95% CI 1.68 to 5.98). The increased risk for maternal mortality was 42.76 and 11.60 for women older than 50 years and for those older than 45 years, respectively, while those for stillbirth was 3.72 and 2.32. The risk of stillbirth and cesarean delivery was significantly higher in women >45 years compared to those aged 40-45, and in those >50 years compared to those aged 45-50. The risk of maternal mortality was significantly higher in women >50 years compared to those aged 40-45 (RR 60.40, 95% CI 13.28 to 274.74).

CONCLUSIONS

The risk of stillbirth, cesarean delivery, and maternal mortality increases with advancing maternal age. The risk ratio for maternal mortality was 3.18, 11.60, and 42.76 in women older than 40, older than 45, and older than 50 years, respectively. These data should be used when women with advanced maternal age are counselled regarding their risk in pregnancy.

Retrospective outcome in women aged 45 years and older undergoing natural cycle IVF treatment

RESEARCH QUESTION

Is natural cycle IVF treatment beneficial to middle-aged women with poor ovarian response?

DESIGN

Retrospective investigation of outcomes in women aged 45 years and older, who underwent natural cycle IVF treatment between 2009 and 2018 in a single assisted reproduction clinic with the aim of reporting several successful outcomes.

RESULTS

In total, 2408 IVF retrievals in women aged 45 years and older were included in this study. Mean serum FSH level on day 3 was 21.4 ± 12.5 (range: 0.3-93.7) IU/ml. One fresh cleavage-stage embryo was transferred in 37.4% (900/2408) of the initiated cycles. The overall clinical pregnancy rate and live birth rate per fresh embryo transfer were 2.8% (25/900) and 0.8% (7/900), respectively. Natural cycle IVF treatment led to seven successful deliveries during the period. All seven women who successfully delivered were poor ovarian responders who met the diagnostic Bologna criteria and, among them, three had elevated serum FSH levels on day 3 (range: 39.0-47.1 mIU/ml). All seven had full-term delivery, and no congenital abnormalities were observed in their infants. No significant difference was found in serum FSH level on day 3 between those with and without positive beta-HCG test results.

CONCLUSIONS

These findings suggest that natural cycle IVF treatment could be an option for older poor responders in countries that do not permit egg donation. Careful counselling is required, however, because of the low probability of live births after IVF in middle-aged women.

The clinical outcomes of fresh versus frozen embryos transfer in women ≥40 years with poor ovarian response

Objective

To compare the clinical outcomes of fresh embryo transfers (ETs) and frozen-thawed embryo transfers (FETs) after a freeze-all cycle in women ≥40 years old with poor ovarian response (POR).

Methods

We performed a single-center, retrospective, case-control study of patients who underwent in vitro fertilization between January 2014 and June 2019. We included a total of 192 patients aged 40 years or older from whom 3 or fewer oocytes had been retrieved and who were receiving cleavage-stage ET in this study. Of these patients, 101 and 91 patients underwent fresh ET and FET, respectively. The primary outcome was the live birth rate (LBR) after the first ET. Logistic regression analysis was used to compare the IVF outcomes and neonatal characteristics between the fresh ET and FET groups, adjusting for maternal age, body mass index, luteinizing hormone, and the number of good quality embryos transferred.

Results

The mean maternal ages and number of oocytes retrieved (43.2 years and 2.3 in both groups, P=0.902 and P=0.927, respectively) were similar in the fresh ET and FET groups. No significant difference was observed between the LBRs of the fresh ET and FET groups (adjusted odds ratio, 1.28; 95% confidence interval, 0.29–5.70). The clinical pregnancy and miscarriage rates, and neonatal characteristics (birth weights and premature infant rates) were similar between the 2 groups.

Conclusions

FET after the freeze-all strategy had no beneficial impact on the clinical outcomes of women ≥40 years with POR.

IVF in women aged 43 years and older: a 20-year experience

RESEARCH QUESTION

What are the reproductive outcomes of women aged 43 years and older undergoing IVF and intracytoplasmic sperm injection (ICSI) treatment using their own eggs.

DESIGN

Retrospective study of 833 woman aged 43 years or older undergoing their first IVF and ICSI cycle using autologous oocytes at a tertiary referral hospital between January 1995 and December 2019. Live birth rate (LBR) after 24 weeks' gestation was the primary outcome.

RESULTS

Ninety-five out of 833 (11.4%) had a positive HCG, whereas 59 (62.1% per positive HCG) had a miscarriage before 12 weeks' gestation and 36 (4.3%) live births were achieved. Analysis by age showed that the number of cumulus-oocyte complexes retrieved was significantly different between the four age groups: 43 years (5 [3-9]); 44 years (5 [2-7]); 45 years (3 [2-8)]); ≥45 years (2.5 [2-6]); P < 0.01; the number of metaphase II oocytes, however, was similar. Positive HCG rates remained low: 43 years (78/580 [13.4%]); 44 years (14/192 [7.3%]); 45 years (1/39 [2.6%]; and ≥46 years (2/22 [9.1%]); P = 0.03, as did LBR: 43 years (28 [4.8%]); 44 (7 [3.6%]); 45 years (0 [0%]); and ≥46 years (1 [4.5%]); P = 0.5. Multivariate regression analysis revealed that only number of metaphase II was significantly associated with LBR, when age was considered as a continuous (OR 1.08, 96% CI 1.004 to 1.16) or categorical variable (OR 1.08, 95% CI 1.005 to 1.16).

CONCLUSION

The chances of achieving a live birth in patients aged 43 years and older undergoing IVF/ICSI with their own gametes are low, even in cases of patients with a relatively 'normal' ovarian reserve for their age.

Cumulative live birth rates and number of oocytes retrieved in women of advanced age. A single centre analysis including 4500 women ≥38 years old

STUDY QUESTION

Is there any relationship between the number of oocytes retrieved and cumulative live birth rates (CLBRs) in women of advanced age?

SUMMARY ANSWER

CLBRs increase with the number of oocytes retrieved in women of advanced reproductive age up to 41 years old, the added value is minimal in women more than 41 years and futile in women 44 years or older.

WHAT IS KNOWN ALREADY

CLBR is actually the most relevant outcome of IVF from patients' perspective. There are several studies that have analysed CLBR's but some of them have included several stimulation cycles, others have not included the frozen embryo transfers (FETs) in their analysis and none has focused on women of advanced reproductive age. We aimed to assess CLBR in women ≥38 years after a single stimulation cycle plus the subsequent frozen embryo transfers.

STUDY DESIGN, SIZE, DURATION

This is a retrospective analysis carried out in a University-affiliated tertiary centre between January 2000 and December 2013. Overall, 4570 infertile women aged ≥38 years who underwent their first cycle in our centre were included.

PARTICIPANT/MATERIALS, SETTING, METHODS

Patients were categorized in four age-groups: 38-39 years (G1 = 1875 cycles), 40-41 years (G2 = 1380 cycles), 42-43 years (G3 = 833 cycles) and ≥44 years (G4 = 482 cycles). CLBR's were evaluated by adding the pregnancies and live births achieved in the FET's to the ones obtained in the fresh cycle. In order to find out the actual effect of the number of oocytes retrieved in these patients, a predictive model of CLBR according to age and oocyte yield was built.

MAIN RESULTS AND THE ROLE OF CHANCE

CLBRs significantly decrease with increasing age among women ≥38 years of age, with the most prominent and clinically relevant decline observed at 42-43 years old, and clear evidence for futility in women aged ≥44 years (25.9% at 38-39 years, 16.4% at 40-41 years, 7% at 42-43 years and 1.2% from 44 years onwards). The higher the number of oocytes retrieved, the higher the CLBR; however, this is more evident up to 41 years old and no clear benefit is observed from 44 years and beyond.

LIMITATIONS, REASONS FOR CAUTION

Limitations are related to the retrospective nature of the study; however, no significant differences were observed in the treatment protocols used. Other potential limitations could be the fact that embryo cryopreservation was carried out with slow freezing in 80% of cases and that a small proportion of patients still have frozen embryos; nevertheless, we do not expect a relevant impact of these issues as slow freezing showed excellent results that did not differ significantly compared to vitrification and, on the other hand, the extra benefit coming from the FETs was very limited.

WIDER IMPLICATIONS OF THE FINDINGS

The number of oocytes retrieved is significantly associated with CLBR also in women of advanced reproductive age. However, the added benefit appears to be restricted mainly in women up to 41 years old. Women over 43 do not experience any benefit in CLBR irrespective of the number of oocytes retrieved, and thus should be discouraged from doing an IVF cycle with their own oocytes; for the other age-groups, recommendations should be given considering the age and the expected ovarian response.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

NA.

Mid-life fertility: Challenges & policy planning

This review highlights the challenges, priority areas of research and planning, strategies for regulation of services and the need to develop guidelines and laws for fertility treatments during mid-life. The success rate of all treatments is poor in advanced age women because of declining ovarian reserve and natural fertility. There is often a need of third-party involvement which has its own ethical, legal and medical issues. Welfare of children born to older women and early death of parents are important concerns. Most of the new techniques such as the pre-implantation genetic diagnosis, oocyte augmentation, use of stem cells or artificial gametes, ovarian tissue preservation and ovarian transplantation are directed to improve, preserve or replace the declining ovarian reserve. These techniques are costly and have limited availability, safety and efficacy data. Continued research and policies are required to keep pace with these techniques. The other important issues include the patients' personal autonomy and right of self-determination, welfare of offspring, public vs. private funding for research and development of new technologies vs. indiscriminate use of unproven technology. It is important that mid-life fertility is recognized as a distinct area of human reproduction requiring special considerations.

Herbal fertility treatments used in North America from colonial times to 1900, and their potential for improving the success rate of assisted reproductive technology

This paper serves to fill a gap in the literature regarding evidence for the use of botanical remedies in the promotion of fertility. It examines the botanical remedies that were used in North America (1492-1900) for all stages of reproduction from preconception to birth, and discusses their potential for future use with present-day infertility treatments. Each medicinal plant discussed in this paper is assessed using an ethnomedicinal methodology that entails examining the published ethnobotanical, phytochemical and pharmacological data. A few clinical trials have shown that there is potential for medicinal plants to improve the success rate of assisted reproductive technology (ART) treatment if used in an integrated manner, similar to the integrated use of traditional Chinese medicine with ART treatment. For example, research has shown that older women who become pregnant have a high miscarriage rate, and this is one area that complementary and alternative medicines can address.

Double ovarian stimulation during the follicular and luteal phase in women ≥38 years: a retrospective case-control study

Previous studies have shown that double ovarian stimulation could obtain more oocytes in women with poor ovarian response. This retrospective case-control study aimed to investigate the efficacy of double ovarian stimulation in older women. One hundred and sixteen women aged ≥38 years who received double ovarian stimulation were assigned to the study, with 103 divided into four groups according to follicular-phase ovarian stimulation protocols, including gonadotrophin-releasing hormone agonist short protocol (n = 27), gonadotrophin-releasing hormone antagonist protocol (n = 32), mild stimulation protocol (n = 21) and medrocyprogesterone acetate (MPA) pituitary down-regulation protocol (n = 23). Numbers of oocytes retrieved and available embryos after double ovarian stimulation were more than double those obtained after follicular-phase ovarian stimulation alone. In total 81.90% of patients had available embryos, and the cancellation rate decreased from 37.07% to 18.10%. Forty-eight cases underwent 50 cryopreserved embryo transfer cycles, with a 22.00% clinical pregnancy rate. The implantation rate (10.53% versus 10.67%) was similar between the embryos derived from first and second stimulations. The results suggest that double ovarian stimulation could increase the chances of achieving pregnancy by accumulating more oocytes/embryos in a short time, which might serve as a useful strategy for older women.

Predictors of live birth and pregnancy success after in vitro fertilization in infertile women aged 40 and over

Objective

The aim of this study was to evaluate pregnancy outcomes and the live birth rate at 1-year age increments in women aged ≥40 years undergoing fresh non-donor in vitro fertilization (IVF) and embryo transfer (ET), and to identify predictors of success in these patients.

Methods

This retrospective study was performed among women ≥40 years of age between 2004 and 2011. Of the 2,362 cycles that were conducted, ET was performed in 1,532 (73.1%).

Results

The clinical pregnancy rate and live birth rate in women ≥40 years significantly decreased with each year of increased age (p<0.001). Maternal age (odds ratio [OR], 0.644; 95% confidence interval [CI], 0.540–0.769; p<0.001), basal follicle-stimulating hormone (FSH) levels (OR, 0.950; 95% CI, 0.903–0.999; p=0.047), the number of high-quality embryos (OR, 1.258; 95% CI, 1.005 –1.575; p=0.045), and the number of transferred embryos (OR, 1.291; 95% CI, 1.064 –1.566; p=0.009) were significant predictors of live birth. A statistically significant increase in live birth rates was seen when ≥3 embryos were transferred in patients 40 to 41 years of age, whereas poor pregnancy outcomes were seen in patients ≥43 years of age, regardless of the number of transferred embryos. Moreover, the cumulative live birth rate increased in patients 40 to 42 years of age with repeated IVF cycles, but the follicle-stimulating hormone in those ≥43 years of age rarely showed an increase.

Conclusion

IVF-ET has acceptable outcomes in those <43 years of age when a patient's own oocytes are used. Maternal age, basal FSH levels, and the number of high-quality embryos and transferred embryos are useful predictors of live birth.

National trends and outcomes of autologous in vitro fertilization cycles among women ages 40 years and older

PURPOSE

The purpose of the study was to describe trends in and investigate variables associated with clinical pregnancy and live birth in autologous in vitro fertilization (IVF) cycles among women ≥40 years.

METHODS

We used autologous IVF cycle data from the National ART Surveillance System (NASS) for women ≥40 years at cycle start. We assessed trends in fresh and frozen cycles (n = 371,536) from 1996 to 2013. We reported perinatal outcomes and determined variables associated with clinical pregnancy and live birth in fresh cycles between 2007 and 2013.

RESULTS

From 1996 to 2013, the total number of cycles in women ≥40 years increased from 8672 to 28,883 (p < 0.0001), with frozen cycles almost tripling in the last 8 years. Cycles in women ≥40 years accounted for 16.0% of all cycles in 1996 and 21.0% in 2013 (p < 0.0001). For fresh cycles from 2007 to 2013 (n = 157,890), the cancelation rate was 17.1%. Among cycles resulting in transfer (n = 112,414), the live birth rate was 16.1%. The following were associated with higher live birth rates: multiparity, fewer prior ART cycles, use of standard agonist or antagonist stimulation, lower gonadotropin dose, ovarian hyperstimulation syndrome, more oocytes retrieved, use of pre-implantation genetic screening/diagnosis, transferring more and/or blastocyst stage embryos, and cryopreserving more supernumerary embryos. Of the singleton infants born (n = 14,992), 86.9% were full term and 88.3% normal birth weight.

CONCLUSIONS

The NASS allows for a comprehensive description of IVF cycles in women ≥40 years in the USA. Although live birth rate is less than 20%, identifying factors associated with IVF success can facilitate treatment option counseling.

Pregnancies in Women Aged 45 Years and Older - a 10-Year Retrospective Analysis in Berlin

Introduction Improved fertility treatment options and a change in the socio-cultural concept of family planning, especially in industrialized regions, has led to an increasing number of births by women of advanced maternal age, which is associated with a higher rate of complications. The aim of this study was to analyze pregnancy outcomes in women aged ≥ 45 years in an inner-city German hospital and to compare these results to those of a younger cohort. Materials and Methods Over a 10-year period from January 2004 to May 2015, the pregnancy outcomes of all 186 women aged ≥ 45 years who delivered in our hospital were compared in a 1 : 1 ratio to those of a cohort of 29-year old women. Results The rates of assisted reproduction (34 vs. 3 %), multiple pregnancies (16 vs. 5 %) and cesarean section (59 vs. 29 %) were significantly increased in the study group. There was an increased risk of preterm delivery (28 vs. 11 %), preeclampsia, gestational diabetes and premature rupture of membranes in the advanced maternal age group. Conclusion Advanced maternal age leads to higher rates of fetal and maternal complications. These findings should be taken into account when planning assisted reproduction and obstetrical care in women with advanced maternal age.

Predictors of pregnancy outcome for infertile couples attending IVF and ICSI programmes

The purpose of this study was to evaluate the predictors of pregnancy outcome for infertile couples attending in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI) programmes. Infertile couples attending IVF or ICSI procedures were included in this study. Related data including semen parameters and male and female age and body mass index were collected and analysed. The main outcome was clinical pregnancy, defined as an ultrasound detection of foetal heartbeat 6 weeks after embryo transfer. A total of 1316 couples who underwent IVF and 266 who underwent ICSI were recruited for this study. A multivariate logistic regression with likelihood ratio test revealed the following predictors of pregnancy outcome: female age and sperm DNA fragmentation index (DFI) and acrosomal activity in IVF procedures (chi-square of likelihood ratio = 26.42, d.f. = 3, P < 0.005) and female age and DFI in ICSI procedures (chi-square of likelihood ratio = 18.88, d.f. = 2, P < 0.005). In conclusion, our study indicated that sperm DFI, female age and acrosomal levels have a significant effect on ART pregnancy outcome.

Treatment and preservation at the extremes of reproductive age: a case report outlining the ethical dilemmas

PURPOSE

The purpose of the study was to report a livebirth from a cryopreserved embryo created from autologous oocytes collected at 47 years and 9 months that outlines the ethical difficulties of decision-making at the extreme of reproductive age.

METHODS

The method used was IVF and embryo cryopreservation within an assisted conception unit prior to adjuvant cancer treatment in a nulliparous patient diagnosed with breast carcinoma (47 years and 9 months at oocyte collection).

RESULTS

A 47-year-old nulliparous woman was diagnosed with breast malignancy during work-up for fertility treatment. Ovarian stimulation yielded one embryo from four oocytes that was cryopreserved to allow completion of adjuvant treatment. Subsequent embryo transfer cycle led to a live birth of a healthy baby girl at term, weighing 3.37 kg.

CONCLUSION

This paper demonstrates the oldest reported age of autologous oocyte collection to have achieved a livebirth. In women where most would consider treatment futile, we highlight the difficulties in decision-making in this group of patients.

Live-birth rates in very poor prognosis patients, who are defined as poor responders under the Bologna criteria, with nonelective single embryo, two-embryo, and three or more embryos transferred

OBJECTIVE

To determine live-birth rates (LBRs) at various ages in very poor prognosis patients, who are defined as poor responders under the Bologna criteria.

DESIGN

Retrospective cohort study.

SETTING

Academically affiliated private fertility center.

PATIENT(S)

Among 483 patients, who under the Bologna criteria (three or fewer oocytes, >40 years of age, and/or antimüllerian hormone [AMH] <1.1 ng/mL [2/3 criteria minimum]) were poor responders, 278 (381 fresh IVF cycles) qualified for the study because they had at least one embryo on day 3 for transfer.

INTERVENTION(S)

IVF cycles in women with low functional ovarian reserve, involving androgen and CoQ10 supplementation and ovarian stimulation with daily gonadotropin dosages of 300-450 IU of FSH and 150 IU of hMG in microdose agonist cycles.

MAIN OUTCOME MEASURE(S)

Age-specific LBRs per ET.

RESULT(S)

Ages did not differ between nonelective (ne) single ET (SET), ne2-ET, and ne ≥ 3-ET cycles (41.3 ± 3.9, 41.7 ± 3.1, and 42.4 ± 2.1 years, respectively). Patients with neSETs demonstrated significantly lower AMH and higher FSH levels and required higher gonadotropin dosages than ne2-ET and ne ≥ 3-ET patients. LBRs declined with age. Above age 42, three or more embryos are required to achieve reasonable LBRs and two or more to avoid futility under American Society for Reproductive Medicine (ASRM) guidelines.

CONCLUSION(S)

Very poor prognosis patients can still achieve acceptable pregnancy rates at least till their mid-40s if they reach ET. The degree to which egg donation is emphasized as the only treatment option in such patients, therefore, requires reconsideration. Above age 42, at least two, and preferably three embryos, are however required to exceed futility, as defined by ASRM.

Oocyte aging underlies female reproductive aging: biological mechanisms and therapeutic strategies

In recent years, postponement of marriage and childbearing in women of reproductive age has led to an increase in the incidence of age-related infertility. The reproductive aging process in women is assumed to occur due to a decrease in both the quantity and quality of the oocytes, with the ultimate result being a decline in fecundity. This age-related decline in fecundity is strongly dependent on oocyte quality, which is critical for fertilization and subsequent embryo development. Aged oocytes display increased chromosomal abnormality and dysfunction of cellular organelles, both of which factor into oocyte quality. In particular, mitochondrial dysfunction has been suggested as a major contributor to the reduction in oocyte quality as well as to chromosomal abnormalities in aged oocytes and embryos. Participation of oxidative stress in the oocyte aging process has been proposed because oxidative stress has the capacity to induce mitochondrial dysfunction and directly damage many intracellular components of the oocytes such as lipids, protein, and DNA. In an attempt to improve mitochondrial function in aged oocytes, several therapeutic strategies have been investigated using both animal models and assisted reproductive technology. Here, we review the biological mechanisms and present status of therapeutic strategies in the female reproductive aging field and indicate possible future therapeutic strategies.

The "graying" of infertility services: an impending revolution nobody is ready for

BACKGROUND

As demand for infertility services by older women continues to grow, because achievable in vitro fertilization (IVF) outcomes are widely underestimated, most fertility centers do not offer maximal treatment options with use of autologous oocytes. Limited data suggest that clinical IVF outcomes in excess of what the American Society for Reproductive Medicine (ASRM) considers "futile" can, likely, be achieved up to at least age 45 years.

METHODS

In an attempt to point out an evolving demographic trend in IVF, we here report our center's IVF data for 2010-2012 and national U.S. data for 1997-2010. Though our center's data are representative of only one IVF center's patients, they, likely, are unique since they probably represent the most adversely selected IVF patient population ever reported and, thus, are predictive of future demographic trends. In addition we performed a systematic review of the literature on the subject based on PubMed, Medline and Google Scholar searches till year-end 2013. The literature search was performed using key words and phrases relevant to fertility treatments in older women.

RESULTS

As demonstrated by our center's patient demographics and national U.S. data, IVF centers are destined to treat increasingly adversely selected patients. Despite our center's already extremely adversely selected patient population, age-specific IVF cycle outcomes in women above age 40 years, nevertheless, exceeded criteria for "futility" by the ASRM and widely quoted outcome expectations in the literature for patient ages. Age 43 discriminates between better and poorer clinical pregnancy and live birth rates.

CONCLUSIONS

"Graying" of the infertility populations in the developed world, a problem with potentially far-reaching medical and societal consequences, has so far been only insufficiently addressed in the literature. As women's postmenopausal life spans already exceed postmenarcheal life spans at the start of the 20th century, the "graying" of infertility services can be expected to further accelerate, no longer as in recent decades bringing only women in their 40s into maternity wards but also women in their 50s and 60s. Medicine and society better get ready for this revolution.

Live birth from a 46-year-old using fresh autologous oocytes through in vitro fertilization

OBJECTIVE

To report a live birth with IVF from a 46-year-old woman using autologous oocytes.

DESIGN

Case report.

SETTING

Reproductive endocrinology and infertility private practice and ambulatory IVF center.

PATIENT(S)

One 46-year-old nulligravid woman.

INTERVENTION(S)

IVF with fresh ET.

MAIN OUTCOME MEASURE(S)

Live birth after IVF.

RESULT(S)

A 46-year-old with antimullerian hormone (AMH) level less than 0.16 conceived through IVF using autologous oocytes. A total of seven oocytes were retrieved, from which four embryos were transferred at the cleavage stage, resulting in a pregnancy and delivery of a healthy male infant weighing 1,580 g at 31 and 3/7 weeks' estimated gestational age.

CONCLUSION(S)

The prognosis for a live birth from IVF in a patient with very advanced reproductive age, particularly with an undetectable AMH level using autologous oocytes, remains extremely poor. This case should be interpreted with caution so as to not provide false hope to women aged 45 and above.

Management of infertility in women over 40

Women's fertility potential is declining with age because of multiples intrinsic and extrinsic factors such as life style, oxidative stress and/or endocrine disruptors and is affecting the ability of these women to conceive naturally. This declining fertility potential and the late age of motherhood is increasing significantly the number of patients consulting infertility specialists. Different strategies of investigation and management are proposed to patients over 40 in order to overcome their infertility and improve the live birth rate in these patients. Intra Uterine Insemination (IUI) in women over 40 is associated with a low rate of ongoing pregnancy and IUI should not therefore be offered always as the first line of treatment. When the predictive factors are positive IVF/ICSI seem to be good alternatives until 43 years of age. Customized ovarian stimulation and flexible laboratory methods such as in vitro maturation (IVM), preimplantation genetic diagnosis (PGD), embryo vitrification and transfer after thawing in subsequent natural or artificial cycles can improve the success rate of ART in patients over 40. Meanwhile, oocyte and embryos donation remain good options for patient over 40 with a bad prognosis and can lead to successful ongoing pregnancies until 45 years of age. Ovarian tissue cryopreservation, oocyte vitrification at the germinal vesicle (GV) stage or metaphase II stage present a breakthrough for fertility preservation but the ideal age for starting fertility preservation is still debated as well as the minimum number of oocytes to be vitrified in order to optimize the chances of pregnancy when needed at an older age. This manuscript reports the results of our own experience from patients older than 40 in the light of the published data and discusses the different therapeutic alternatives which can be proposed to patients over 40 consulting ART centres.

Assisted reproductive techniques

Assisted reproductive technologies (ART) encompass fertility treatments, which involve manipulations of both oocyte and sperm in vitro. This chapter provides a brief overview of ART, including indications for treatment, ovarian reserve testing, selection of controlled ovarian hyperstimulation (COH) protocols, laboratory techniques of ART including in vitro fertilization (IVF), and intracytoplasmic sperm injection (ICSI), embryo transfer techniques, and luteal phase support. This chapter also discusses potential complications of ART, namely ovarian hyperstimulation syndrome (OHSS) and multiple gestations, and the perinatal outcomes of ART.

[How far can we go to oocyte donation? Debates on the risks of late pregnancies]

In France, there is a decline in first-time motherhood influenced by many sociocultural factors thus leading to a reproductive age where fertility decreases and which increase the risks associated with late pregnancy. The oocyte donation in France is subject to The Bioethic law granting no support in infertility beyond past 43 years. Thus, to satisfy their need for maternity, the French use a gift abroad. Then we will report the case of a pregnancy obtained by an oocyte donation, after 42 years, which was complicated. We will discuss the importance of taking into account the risk factors before a support to ART, and the ethical issues raised by this case. After a brief review of French legislative framework governing the practice of oocyte donation, we will evoke ways to improve the coverage needs of it in France.

Very advanced maternal age and morbidity in Victoria, Australia: a population based study

BACKGROUND

In Australia, approximately 0.1% of births occur to women 45 years or older and this rate has been increasing in recent years. There are however, few population based studies examining perinatal outcomes among this age group. The aim of this study was to determine the maternal and perinatal outcomes of pregnancies in women aged 45 years or older compared to women aged 30-34 years.

METHODS

Data on births at 20 or more weeks' gestation were obtained from the Victorian Perinatal Data Collection for the years 2005 and 2006. We examined selected maternal and perinatal outcomes for women of very advanced maternal age (VAMA) aged 45 years or older (n = 217) and compared them to women aged 30-34 years (n = 48,909). Data were summarised using numbers and percentages. Categorical data were analysed by Chi-square tests and Fisher's exact test. Comparisons are presented using unadjusted odds ratios, 95 percent confidence intervals (CIs) and p-values.

RESULTS

Women aged 45 years and older had higher odds of gestational diabetes (OR 2.05; 95% CI 1.3-3.3); antepartum haemorrhage (OR 1.89; 95% CI 1.01-3.5), and placenta praevia (OR 4.88; 95% CI 2.4-9.5). The older age-group also had higher odds of preterm birth between 32-36 weeks (OR 2.61; 95% CI 1.8-3.8); low birth-weight (<2,500 gr) (OR 2.22; 95% CI 1.5-3.3) and small for gestational age (OR 1.53; 95% CI 1.0-2.3). Stratified analysis revealed that VAMA was most strongly associated with caesarean section in primiparous women (OR 8.24; 95% CI 4.5, 15.4) and those using ART (OR 5.75; 95% CI 2.5, 13.3), but the relationship persisted regardless of parity, ART use and plurality. Low birthweight was associated with VAMA only in first births (OR 3.90; 95% CI 2.3, 6.6), while preterm birth was more common in older women for both first (OR 3.13; 95% CI 1.8, 5.3) and subsequent (OR 2.08; 95% CI 1.2, 3.5) births, and for those having singleton births (OR 2.11; 95% CI 1.3, 3.4), and those who did not use ART (OR 2.10; 95% CI 1.3, 3.4). Preterm birth was very common in multiple births and following ART use, regardless of maternal age.

CONCLUSIONS

This study demonstrates that women aged 45 years and older, in Victoria, Australia, have higher rates of pregnancy and perinatal complications, compared to women aged 30-34 years.

Neonatal risks from in vitro fertilization and delayed motherhood

Delayed childbearing (DC) is common in most Western countries. The average age of first-time mothers increased in United States from 21.4 years in 1970 to 25.0 years in 2006 and from 25.4 to 30.8 years in Australia in the same period. It is commonly believed that this has no ominous consequences. But several negative consequences of this behavior are described: stillbirth, prematurity, twins, birth anomalies. Age also decreases women’s fertility, thus many couples undergo in vitro fertilization. And we highlight a paradox: medical reproduction techniques decreases their effectiveness with maternal age, but their availability can be an incentive to postpone parenthood. Of course the risks of delayed parenthood involve a minority of cases, but are parents entitled to accept any risk on the behalf of their baby A complete information would make people cautious before deciding to postpone childbearing, though this is often an obliged rather that a free choice: the consumerist society pressure and the difficulty to find an employment have their heavy weight in this choice. But if this choice is not really free, people’s interest is to overcome these pressures and to claim for a real broad choice on when becoming parent, despite the pressures made by their cultural environment to postpone parenthood. Moreover, even reproductive techniques have some risks. Unfortunately, mass media often praise and endorse DC, disregarding the increase of premature babies born because of DC, a real alarm for public health. Pediatricians should discourage the culture that makes DC a normal event.

The cumulative probability of liveborn multiples after in vitro fertilization: a cohort study of more than 10,000 women

OBJECTIVE

To estimate the cumulative probability of liveborn multiples after IVF to improve patient counseling regarding this significant morbidity.

DESIGN

Retrospective cohort study.

SETTING

Large academic-affiliated infertility practice.

PATIENT(S)

A total of 10,169 women were followed from their first fresh, nondonor IVF cycle through up to six fresh and frozen IVF cycles from 2000-2010.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Delivery of a liveborn infant(s).

RESULT(S)

After three IVF cycles the cumulative live birth rate (CLBR) was 53.2%. The singleton, twin, and triplet CLBRs were 38.0%, 14.5%, and 0.7%. After six IVF cycles the CLBR was 73.8%, with 52.8%, 19.8%, 1.3% for singletons, twins, and triplets. Of the 5,433 live births, 71.4% were singletons, 27.1% were twins, and 1.5% were triplets. Women more than 39 years had the lowest incidence of liveborn multiples with CLBRs of 5.2% after three cycles and 9.5% after six cycles. The twin CLBR doubled from cycles 1 through 3 with the rate of increase slowing from cycles 3 through 6. Although very low in absolute terms, the triplet CLBR also doubled from cycles 1 through 3 and doubled again from cycles 3 through 6. Of the 1,970 pregnancies that began as multifetal on ultrasound, 77.4% resulted in liveborn multiples.

CONCLUSION(S)

Providers should be aware of the cumulative probability of liveborn multiples to effectively counsel patients on this important issue. With nearly three-quarters of all women having live birth after up to six IVF cycles, it is encouraging to report a low incidence of liveborn multiples.

The ethical, legal, and social issues impacted by modern assisted reproductive technologies

Background. While assisted reproductive technology (ART), including in vitro fertilization has given hope to millions of couples suffering from infertility, it has also introduced countless ethical, legal, and social challenges. The objective of this paper is to identify the aspects of ART that are most relevant to present-day society and discuss the multiple ethical, legal, and social challenges inherent to this technology. Scope of Review. This paper evaluates some of the most visible and challenging topics in the field of ART and outlines the ethical, legal, and social challenges they introduce. Major Conclusions. ART has resulted in a tectonic shift in the way physicians and the general population perceive infertility and ethics. In the coming years, advancing technology is likely to exacerbate ethical, legal, and social concerns associated with ART. ART is directly challenging society to reevaluate the way in which human life, social justice and equality, and claims to genetic offspring are viewed. Furthermore, these issues will force legal systems to modify existing laws to accommodate the unique challenges created by ART. Society has a responsibility to ensure that the advances achieved through ART are implemented in a socially responsible manner.

The value of growth hormone supplements in ART for poor ovarian responders

Recently, three meta-analyses have concluded that cotreatment with GH improves assisted reproduction outcome in poor controlled ovarian stimulation responders. Although generally GH supplements did not increase controlled ovarian stimulation response or number of oocytes, the supplements improved pregnancy and live-birth rates-thus speaking for an effect on oocyte quality.

How old is too old for in vitro maturation (IVM) treatment?

OBJECTIVE

Fertility declines with age. A study of the outcomes of in vitro maturation (IVM) in women of different ages has not been reported to date. The aim of our study was to evaluate the impact of age on treatment response and on pregnancy rates after IVM treatment.

STUDY DESIGN

We reviewed the data of all IVM cycles and recorded the total number of oocytes, total metaphase II (MII) oocytes, the number and quality of embryos as well as pregnancy rates. The main outcome measures were number and maturity of retrieved oocytes and pregnancy rates.

RESULTS

Compared to cycles in women ≤25 years, the number of oocytes and total MII oocytes were significantly lower in women over 40 years. The number of good quality embryos in women ≤25 years (3.6±1.7) was higher than in women aged 40 years (0.8±1.2, P<0.0001). The ongoing pregnancy rates in women aged 20-25 years were 36.8%, 26-35 years were 30.0% and in those 36-39 years were 31.9%. No clinical pregnancy was observed in women over the age of 40.

CONCLUSION

Women over 40 years are poor candidates for IVM treatment.

Assisted reproductive technologies: a systematic review of safety and effectiveness to inform disinvestment policy

OBJECTIVE

Health policy relating to assisted reproductive technologies (ART) has been variably informed by clinical evidence, social values, political and fiscal considerations. This systematic review examined key factors associated with specific benefits and harms of ART to inform the development of a model for generating policy recommendations within an Australian disinvestment research agenda.

METHODS

Six databases were searched from 1994 to 2009. Included articles contained data on safety and/or effectiveness of in vitro fertilisation (IVF) or IVF with intracytoplasmic sperm injection with reference to female age, male age or cycle rank. Narrative descriptions of key outcomes (live birth, miscarriage) were constructed alongside tabular summaries.

RESULTS

Sixty-eight studies and one registry report were included. There was substantial heterogeneity present within the evidence-base which limited the strength and scope of conclusions that could be drawn. However, this review does affirm the differential effectiveness associated with the ageing of ART patients with regard to live birth and miscarriage.

CONCLUSION

From the available evidence, it was not possible to determine an explicit age or cycle rank that could be used to formulate defensible policy responsive to identified differential effectiveness. Stakeholder interpretation of this evidence-base may assist in developing policy that can incorporate uncertainty and reflect social values.

[Prognosis criteria for the management of the infertile couple]

Advanced maternal age, obesity and cigarette smoking are associated with decreased fertility, adverse Assisted Reproductive Technologies (ART) outcomes and fetal and neonatal complications. IVF failures increase dramatically in women aged between 42-43 years. Advanced paternal age is associated with fetal and neonatal adverse outcomes. However, it remains uncertain that advanced paternal age could impair IVF results. Obesity (Body mass index more than 30 kg/m(2)) is associated with lower fecundity, pregnancy complications and adverse ART results. The rate of complications is increasing with higher BMI. Cigarette smoking is associated with longer time to conceive and decreased IVF results. In case of infertility associated with obesity or cigarette smoking, physicians have to inform their patient about the benefits of smoking cessation and weight loss. However, maternal age had to be considered as the main prognosis factor before delaying ART because of dietary or smoking cessation program.

Predictive factors of successful pregnancy after assisted reproductive technology in women aged 40 years and older

Purpose

This study aimed to investigate the factors that predict successful pregnancy (live birth) in assisted reproductive technology (ART) for infertile women aged 40 and older.

Methods

Patients who underwent first ART treatments at the age of 40 and older at our institution were enrolled. Several factors which can be evaluated before the first treatments were retrospectively compared among those patients who did and did not achieve live birth.

Results

Nineteen of 119 patients delivered healthy babies. There was no significant difference of live-birth rate among age groups of 40, 41 and 42. No women who underwent the first treatment at age 43 or older achieved live birth. In the successful group, significantly more women held FSH levels under 12 mIU/ml and had regular menstrual cycles (26-32 days) than unsuccessful women of the same age group. In addition, significantly fewer women in the successful group had prior ovarian surgery.

Conclusions

Our results show that low FSH levels, regular menstrual cycles and absence of prior ovarian surgery were related to high live-birth rates and they are good prognostic factors in patients between 40 and 42 years of age. On the other hand, none of these parameters were correlated with success in women aged 43 and older.

Calculating cumulative live-birth rates from linked cycles of assisted reproductive technology (ART): data from the Massachusetts SART CORS

OBJECTIVE

To determine the feasibility of linking assisted reproductive technology (ART) cycles for individual women to compare per-cycle and cumulative live-birth rates.

DESIGN

Historical cohort study.

SETTING

Clinic-based data.

PATIENT(S)

A total of 27,906 ART cycles with residency or treatment in Massachusetts during 2004-2006 and reported to the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System (SART CORS) on-line database.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Per-cycle and cumulative live-birth rates.

RESULT(S)

Linkage of cycles up to and including the first live-birth delivery revealed 14,265 women who averaged 1.9+/-1.2 SD cycles (range 1-11). These cycles yielded 9,452 pregnancies resulting in 7,675 live-birth deliveries. From cycle 1 to cycle 4, the cumulative live-birth rate for all patients increased from 30.4% to 43.3%, 49.1%, and 51.9%, respectively, and plateaued thereafter at about 53%. The cumulative live-birth rate after three cycles using donor oocytes was approximately 60% for women aged<43 years and >50% for women>or=43 years; for autologous oocytes it was 60.1% for ages<35 years and declined steadily to 8.5% for ages>or=43 years.

CONCLUSION(S)

The results demonstrate the feasibility of linking ART cycles for individual women from SART CORS to characterize cumulative live-birth rates.

Intracytoplasmic sperm injection outcome of women over 39: an analysis of 668 cycles

PURPOSE

To evaluate intracytoplasmic sperm injection (ICSI) outcome of women over age 39 and to determine when to discourage such couples to undergo IVF using their own oocytes.

METHODS

Four hundred ninety-five consecutive women (n=668 cycles) over age 39 were evaluated by year-by-year age increments to discriminate the independent prognostic factors for the achievement of pregnancy.

RESULTS

Although the ovarian hyperstimulation performance (COH) and embryological data were not too diverse, the clinical pregnancy rates per embryo transfer decreased from 26 to 13% from age 40 to 44. According to logistic regression, the female age seems to be the only variable in order to predict an ongoing pregnancy. The miscarriage rate increased with advancing female age. It was 33% at age 40 but increased to 100% by age 45.

CONCLUSIONS

The performance of COH and embryological data is not discouraging among women over 39 years in ICSI cycles. However, increased miscarriages as well as decreased implantation rate are mainly responsible for the poor performance of patients with advanced female age. Irrespective of the ovarian reserve testing, ICSI may be refused at age 45 and thereafter.

Too old for IVF: are we discriminating against older women?

In vitro fertilization (IVF) in women of advanced age (>42 years) represents only 5%, a comparatively minute part, of the national IVF experience in the United States (US). In view of evolving population dynamics, it, however, also represents proportionally a rather quickly expanding patient need. Because of access restrictions at many IVF programs, this market does not live up to its potential. As best demonstrated by the 2004 US National Summary and Fertility Clinic Report, which for the first time reported pregnancies and births above age 45 year, IVF in women of advanced reproductive age represents a cutting edge area of interest for improving current IVF outcomes. Access to IVF should, therefore, not be withheld based on female age and/or baseline FSH levels. Instead, a definition of acceptable minimal pregnancy and life birth rates could be used to define the limits of offered access to IVF, independent of age and/or baseline FSH levels.